Outpatients, interpreters and FODMAPS

Leamington Spa's 'Justice Centre' Jan 2011

I am starting to enjoy my outpatient clinics. One of the main reasons for this is that I am no longer scared of them, no longer worried that I won't know the answer, or won't know what to say. They are still difficult and tiring: three and a half hours on a Tuesday morning, with slots for up to three new and eight follow-up appointments. I would be very surprised if any Dietitian has actually managed to see eleven patients, though, because usually fewer are booked in, or at least one patient doesn't turn up. This is actually the only thing that makes a clinic manageable - I don't quite know how I could possibly cope if all the scheduled patients did turn up. Last week one of my colleagues had ten patients, and she had a student with her. She deserves a medal.

I have also had an unusual number of patients who require interpreters. Neither of the other junior Dietitians have needed any interpreters at all, but so far, in about ten clinics, I have needed interpreters for Punjabi (twice), Persian, Kurdish, French (North African), and English (Sign Language for a deaf patient).

Up to now the system has worked in that nobody has turned up without an interpreter, and I have been given extra time for a consultation that includes an interpreter - except last week when I had only fifteen minutes for what was effectively a first appointment, which should have been allocated thirty minutes, even without the need for interpretation. Luckily, the patient didn't turn up. Unluckily, the interpreter did.

Using an interpreter is slow and difficult, especially when there is something complicated or sensitive to discuss, such the foods that do or don't contain gluten (how do you say 'rye' or 'buckwheat'?) or the workings of the bowels. Talking about the consistency of poo with a stranger is difficult enough without having someone else you've never met and who has no health qualification involved in the conversation as well.

Irritable Bowel Syndrome, or IBS, is one of the most frequent conditions that I see in my outpatient clinic. It's not really a disease, it's what's left when all the other likely diseases have been eliminated. If you have chronic bloating, wind, diarrhoea or constipation and you don't have a malignancy or tumour, or coeliac disease, or inflammatory bowel diseases like Crohn's Disease or Ulcerative Colitis, then IBS is what's left.

Treatment: well, there isn't really any treatment other than trying to identify what's causing the symptoms and eliminating that. It could be stress rather than anything physiological, or an intolerance to a food or ingredient, or not enough fluid or fibre, or the wrong type of fibre. A recent innovation is the FODMAP diet, where foods are eliminated that contain Fermentable Oligo-, Di-, Mono-saccharides and Polyols. These are short and medium chain length carbohydrates (compared with the long chain polysaccharides that comprise starch and cellulose), and it is thought that trying to digest them may cause some of the symptoms of IBS for some people.

Digestion takes place mostly in the small intestine, where transit time is relatively brief and enzymes excreted by the pancreas, liver, gall bladder and the gut chop up the food into its constituent parts so they can be absorbed through the wall of the intestine into the bloodstream or lymphatic system. A lot of fluid is needed for this task, so when the undigested remainder of our meals passes into the large intestine, the main job is to recover all that fluid so we don't dehydrate (which is the main problem with diarrhoeal diseases like dysentery and cholera).

But quite a lot of potentially digestible material still remains, such as these FODMAPs. The huge number of bacteria that colonise the lower intestines can perform this function on our behalf, chopping up the FODMAPs, allowing us to absorb potentially useful molecules, but generating gas as they do so. Eliminating FODMAPs from the diet might bring relief to someone who suffers with wind, bloating or diarrhoea.

Unfortunately, it's no easy thing to eliminate FODMAPs, which are present in many different foods. It takes a lot of effort and creativity as well as time to remember lists of foods, read food labels and avoid many social situations that include eating, for six to eight weeks. If there is no relief, then either FODMAPs are not to blame, or else the task of achieving their exclusion is too hard. If excluding FODMAPs is of benefit, then there is a protracted period of re-introduction, to try and ensure that foods are not unnecessarily excluded from the diet.

If all this doesn't work, then there is the Exclusion diet, where you cut down to a very few foods and gradually reintroduce things one at a time. This is almost as hard as the low FODMAP option, and takes just as long. In the end, IBS is not like Crohn's or coeliac disease, because eating foods that cause symptoms does no underlying damage to the body, it's just a matter of deciding how much effort you're prepared to put in to identify troublesome foods compared with the pain or discomfort of the symptoms.

Outpatient clinic

Lakeside, May 2011

Outpatient clinics are stressful, from my point of view, anyway. I don't know whether the patients find them quite so difficult, since all they experience is the frustration of almost always being seen later than their appointment time. Although parking at the hospital is enough to make anyone feel cross when they finally reach their clinic waiting room.

My clinic runs from 9.00 a.m. to 12.30 p.m., at least in theory. New patients get half an hour, follow ups only fifteen minutes. Four minutes late and you might have lost a quarter of your appointment time, except I'll probably have to run late because there's no way I can complete any sort of sensible consultation in eleven minutes. Four minutes early and you're probably going to wait for half an hour because the people before you were late or were particularly chatty or had complex conditions that needed some extra time.

I sit in my clinic room with the patients' cards and the computer showing the clinic list. I have reviewed the cards in advance so I have an idea of what I'm going to encounter, and have a chance to research any conditions I haven't come across before (this is starting to seem pointless; see below). Every minute or so, I press the 'Refresh' button, which re-loads the list and shows if anyone has checked in at the reception desk.

It is 9.18, and it seems my 9.00 patient has DNA'd (Did Not Attend) and my 9.15 is late. I click 'Refresh'. The updated screen shows that at 9.17, the 9.00, 9.15 and 9.30 patients all turned up together. Oh boy. What a great start to the morning.

Or, it is 8.58 and my first patient is at 9.15. I click 'Refresh'. The updated screen shows that the 9.30 patient has already arrived, so I can see him at 9.00 and get ahead. What a great start to the morning!

Here are some examples of consultations, which have been changed from the real ones, but are close enough to give you an idea.

The referral states that the patient has IBS (Irritable Bowel Syndrome) with symptoms of diarrhoea. I'm a bit shaky on the guidelines, so I make sure I have copies ready for us to go through. The patient arrives: IBS is old hat, the latest diagnosis is colitis, which is what the subject of the consultation will be. And we discover that I don't know what you actually do with golden linseeds.

The referral asks me to advise on a diet that will help a type 2 diabetic reduce blood sugars. A typical day's diet history is faultless in terms of sugar, saturated fat and complex carbohydrate intake, and when I check the results on the computer the last tests were done in 2010 and show all blood results within the desired range. Both of us are confused.

The referral states the patient has a Syndrome that I've never heard of. I do a fair amount of research in advance into what it is - it turns out to be a relatively rare endocrine condition marked by excessive hormone production - and I fail to find any relevant dietary guidelines. We will have to work it out together. The patient DNA's.

The card shows that a very overweight patient wants to lose weight, having tried for ages without success. The patient arrives and announces that thanks to a support group, 5 kg has already been lost, and motivation remains to lose more. All I have to do is say thank you for taking the trouble to come and let me know! And write to the GP.

The card shows that the patient needs in-depth dietary advice, and only speaks Urdu. It is 30 minutes before the patient's appointment at the start of the clinic, and I have no idea whether an interpreter has been arranged, or what to do if there hasn't. The admin team arrives and saves the day, showing me how the system shows that an interpreter has been booked. We manage very well, although some concepts don't translate well - I was very confused about 'fish fingers' until it became clear it wasn't the conventional sort.

After the clinic, I have to make sure that all the notes are written up on the cards, and each patient is 'outcomed' on the computer (a nice example of verbing of nouns) so that follow-up appointments can be arranged. Letters are written to the referrers of new patients, if there has been a change in treatment and a new prescription is needed from the GP, or if the patient has been discharged. This week's ambitious target was to try to get all of this admin done on the same day as the clinic, and I managed it!

The manager of the department is very supportive, and encourages using pro forma letters. She didn't exactly say that we didn't have to write when a patient is discharged, but gave the strongest impression that it wouldn't be considered unacceptable. I am still suffering from having to take days off as Annual Leave or forfeit them altogether, meaning that I have to squeeze five days of work into just four, but I'm still writing discharge letters; I think it's the right thing to do.